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Carpal Tunnel

Carpal tunnel syndrome (CTS) is a relatively common condition that causes pain, numbness and a tingling sensation in the hand and fingers.

Usually, these sensations develop gradually and start off being worse during the night. They tend to affect the thumb, index finger, middle finger and half of the ring finger.

Other symptoms of carpal tunnel syndrome include:

It is a painful progressive condition caused by compression of a key nerve in the wrist.

 

What is carpal tunnel?

There are eight small bones called carpal bones in the wrist. A ligament (also called retinaculum) lies across the front of the wrist. Between this ligament and the carpal bones is a space called the carpal tunnel. The tendons that attach the forearm muscles to the fingers pass through the carpal tunnel. A main nerve to the hand (median nerve) also goes through this tunnel before dividing into smaller branches in the palm.

The median nerve gives feeling to the thumb, index and middle fingers, and half of the ring finger. It also controls the movement of the small muscles at the base of the thumb.

Carpal Tunnel

What is carpal tunnel syndrome?

This syndrome is a set of symptoms which is thought to be caused by compression (squashing) of the median nerve in the carpal tunnel. About 1 in 1,000 people develops this syndrome each year. Most cases occur in people aged in their 40s and 50s, but it can occur at any age. It is also common during pregnancy. Women are affected 2-3 times more often than men.

What are the symptoms of carpal tunnel syndrome?

  • Pins and needles. This is tingling or burning in part, or all, of the shaded area shown above. This is typically the first symptom to develop. The index and middle fingers are usually first to be affected.
  • Pain in the same fingers may then develop. The pain may travel up the forearm.
  • Numbness of the same finger(s), or in part of the palm, may develop if the condition becomes worse.
  • Dryness of the skin may develop in the same fingers.
  • Weakness of some muscles in the fingers and/or thumb occurs in severe cases. This may cause poor grip and eventually lead to muscle wasting at the base of the thumb.

Symptoms can vary from person to person from mild to severe. One or both hands may be affected. Symptoms tend to come and go at first, often after you use the hand. Typically, symptoms are worse at night and may wake you up.

The symptoms may be eased for a while by raising the hand up or hanging it down. Flicking the wrist may also give relief. Symptoms persist all the time if the condition becomes severe.

What causes carpal tunnel syndrome?

  • In most cases it is not clear why it occurs. It is thought that some minor changes occur in the tendons and/or other structures going through the carpal tunnel. This may cause an increase in pressure within the tunnel. The increase in pressure is thought to compress and restrict the blood supply to the median nerve. As a result, the function of the median nerve is affected causing the symptoms. Carpal tunnel syndrome is more common in manual workers, especially with jobs using a lot of wrist movement such as scrubbing or wringing. So, overuse of the hand may be a factor in some cases to trigger the changes in the structures in the carpal tunnel, leading to this condition developing.
  • Your genes may play a part. There seems to be some hereditary (genetic) factor. About 1 in 4 people with carpal tunnel syndrome has a close family member (father, mother, brother, sister) who also has or had the condition.
  • Bone or arthritic conditions of the wrist such as rheumatoid arthritis or wrist fractures may lead to carpal tunnel syndrome.
  • Various other conditions are associated with carpal tunnel syndrome. For example: pregnancy, obesity, an underactive thyroid, diabetes, the menopause, other rare diseases, and a side-effect of some drugs. Some of these conditions cause water retention (oedema) which may affect the wrist and cause carpal tunnel syndrome.
  • Rare causes include cysts, growths, and swellings coming from the tendons or blood vessels passing through the carpal tunnel.

martin whiteDo I need any tests?

Often the symptoms are so typical that no tests are needed to confirm the diagnosis.

If the diagnosis is not clear then a test to measure the speed of the nerve impulse through the carpal tunnel may be advised (nerve conduction test). A slow speed of impulse down the median nerve will usually confirm the diagnosis.

  Treatment

What are the treatment options for carpal tunnel syndrome?

General measures

Try not to over-use your wrist by excessive squeezing, gripping, wringing, etc. If you are overweight, losing some weight may help. Painkillers may be prescribed to ease the pain. If the condition is part of a more general medical condition (such as arthritis) then treatment of that condition may help.

Not treating may be an option

In up to 1 in 4 cases the symptoms go without treatment within a year or so. (In about 2 in 3 cases that develop during pregnancy the symptoms go after the baby is born.) So, not treating is an option, particularly if symptoms are mild. The situation can be reviewed if symptoms get worse. Symptoms are most likely to go in people less than 30 years old.

A wrist splint

A removable wrist splint (brace) is often advised as a first active treatment. The aim of the splint is to keep the wrist at a neutral angle without applying any force over the carpal tunnel so as to rest the nerve. This may cure the problem if used for a few weeks. For example, in one research trial comparing splinting with surgery, about 1 in 3 people treated with a splint was satisfied with the relief of symptoms it gave. A splint may be a bit cumbersome to use during the daytime. However, it is common to wear a splint just at night, which is often sufficient to ease symptoms.

A steroid injection

An injection of steroid into, or near to, the carpal tunnel is an option. One research trial found that a single steroid injection eased symptoms in about 3 in 4 cases. In this trial the symptoms returned in some people. However, about half of the treated people were free of symptoms a year later. Other studies report variable success rates with steroid injections. It is not clear how steroids work in this condition. Steroids are known to reduce inflammation. However, there is no obvious inflammation in most cases. Steroids also reduce the effect of other chemicals, which may play a part in increasing the pressure within the carpal tunnel.

Relaxed patient during Carpal Tunnel surgerySurgery

A small operation can cut the ligament over the front of the wrist and ease the pressure in the carpal tunnel. This usually cures the problem. It is usually done under local anaesthetic. You will not be able to use your hand for work for a few weeks after the operation. A small scar on the front of the wrist will remain. There is a small risk of complications from surgery. For example, following surgery there is a small risk of infection and damage to the nerve or blood vessels.

Other treatments

Over the years, a wide range of other treatments have been advocated. For example, diuretics (water tablets), exercises, vitamin B6, chiropractic manipulation of the wrist, yoga, magnet therapy, and treatment with ultrasound. None of these treatments has good research evidence to support its use and so they are not commonly advised. Steroid tablets may ease symptoms in some cases. However, there is a risk of serious side-effects from taking a long course of steroid tablets. Also, a local injection of a steroid (described above) probably works better. Therefore, steroid tablets are not usually advised.

Which is the best treatment for me?

A nonsurgical option may be advised if symptoms are mild. For example, if symptoms come and go and mainly consist of tingling, pins and needles or mild discomfort. A splint may work but a steroid injection is probably the most effective nonsurgical treatment.

If you try a nonsurgical treatment and it does not work, do return to your doctor. In particular, if you have constant numbness in any part of your hand, or if you have any weakness of the muscles next to the thumb. These symptoms mean that the nerve is not working well and is at risk of permanent damage.

Surgery gives the best chance of long-term cure. It is quite a common operation. It is done if symptoms persist despite other treatments, or if symptoms are severe and the nerve is in danger of permanent damage.

Treatment for severe symptoms

If you have severe symptoms, in particular wasting of the muscles at the base of the thumb, then you will probably need surgery. This is to decompress the trapped nerve quickly which aims to prevent any permanent long-term damage to the nerve.

Carpal tunnel syndrome during pregnancy

Symptoms commonly go after the baby is born. Therefore, a nonsurgical treatment, such as a splint, is usually advised at first. Surgery is an option if symptoms persist.

 Further Information

Carpal-Tunnel.net

Web: www.carpal-tunnel.net
A website written by a British doctor who has a special interest in carpal tunnel syndrome. This website gives detailed information aimed at the general public on all aspects of the condition and its treatment options.

 After treatment

Advice Following Carpal Tunnel Release

Martin with patient

How do I care for my dressing?

Remove the wool and crepe bandages yourself at home in 2 days’ time if these bandages feel tight at any time during the 2 days please loosen them off yourself. Try and keep the dressing on the palm of your hand dry and intact until the steristrips fall off – you will get some spare dressings on the day of your operation.

Do I need to take painkillers?

We recommend you can take 2 Paracetamol tablets 1 hour following your operation (provided you are not allergic to them). Thereafter, take 2 every 6 to 8 hours, but no more than 8 in 24 hours, on an as needs basis. Paracetamol tablets are available over-the-counter from pharmacists and other stores. Many people experience pins and needles for several hours following their operation this is very common and does generally settle down by the end of the day.

When can the stitches come out?

The wool and crepe bandage can be removed 48 hrs after your operation. The stitches used to close the wound do not need removing. They are placed under the skin and dissolve away. The steristrips that the doctor placed over the wound do not need removing and will fall off of their own accord. There is no need to remove them.

Do I need to do exercises?

Start doing finger exercises at least every hour after your operation. Bend and stretch the fingers. The exercises help to reduce any swelling and stiffness. We advise that you start to use your hand immediately to do whatever is comfortable for you to do. Gradually you will be able to do more and more.

What if my fingers become swollen?

Keep an eye on your fingers if they do become swollen you need to elevate your hand to alleviate the swelling this can be done by placing your hand on your chest or laying your hand on a pillow next to you.

If you have a lot of swelling, please contact us so we can arrange for you to come and see one of our nurses. If this is inconvenient, please contact your own GP practice to see the practice nurse there. She will remove your dressing, inspect the wound and then re-dress your hand.

When can I bath or shower?

You can bath or shower the evening after your operation. It is very important to keep the dressings dry. Put a plastic bag over your hand or wrap it in cling film and keep your hand well out of the bath/shower area.

Scar tenderness

The doctor will have explained before the operation that the scar after the steristrips have fallen off will be tender, more so when taking weight through the wrist for example when pushing yourself up off the chair arm. The tenderness and suppleness of the scar will settle but takes time. One way to try to improve the tenderness quicker is massage. Once the steristrips fall off we would ask you to massage the scar with your thumb of the hand that hasn't been operated on. Any moisturiser or bio oil helps. Massage the scar 4-5 times a day reasonably firmly to the point at which it is tender. With time you will find the tenderness resolves and you will be able to do more with the hand. Your grip strength will also return to normal. It is important to realise that this process takes weeks to months rather than days to weeks.

Complications, Risks and Prognosis

Any surgical procedure has an element of risk attached to it and occasionally things do not turn out as well as expected. The first thing the patient considering surgery wants to know is… will it work? The quick answer for carpal tunnel decompression is given here in the form of what over 6000 patients in East Kent reported after their carpal tunnel surgery when asked.

Outcome of CT Operations

  • About half consider the hand to be 'as good as new' after the operation
  • Three quarters are generally happy with the result
  • 87% are at least improved.

If you have severe carpal tunnel syndrome the likelihood of success following surgery is not as good. What we do know is that if you do go on to have surgery:

1) If your main symptoms are pain/tingling these can be expected to improve

2) If you are troubled by weakness of the hand this may improve in 50-80% of cases, but will take time

3) Your prospects are worse if you are older or have other problems such as diabetes

4) If your main complaint is numbness there is a modest risk of having more pain/tingling after surgery

The tenderness and suppleness of the scar will settle following our post-operative guidance but takes time. It is important to realise that this process takes weeks to months rather than days to weeks.

What problems should I look out for?

If you have a lot of pain, swelling of the fingers and a possible temperature, you may have an infection. Please contact us as soon as possible on 01900 233170. Out of hours you should contact Cumbria Health ON Call (CHOC) 03000 247 247

If you have bleeding coming through the bandage, apply pressure for 30 minutes and contact us as soon as possible on 01900 233170. Out of hours you should contact CHOC

Please contact us in the first instance, rather than your own GP surgery if you have any queries or problems.